The benefits of aspirin in early secondary stroke prevention

312 www.thelancet.com Vol 388 July 23, 2016 Aspirin is considered an aff ordable and widely available, if only modestly eff ective, thromboprophylactic for secondary stroke prevention. The two large randomised controlled trials of aspirin in acute ischaemic stroke reported that aspirin reduced the odds of early recurrent stroke at 2–4 weeks by about 12% (odds ratio [OR] 0·88, 95% CI 0·79–0·97) and the odds of death or dependency at the end of follow-up by about 5% (OR 0·95, 0·91–0·99). The ten trials of aspirin for long-term secondary prevention in patients with previous transient ischaemic attack (TIA) or ischaemic stroke reported that aspirin reduced the risk of any recurrent stroke over 3 years by about 17% (relative risk [RR] 0·83, 95% CI 0·72–0·96). However, non-randomised observational studies have suggested that urgent medical treatments, including aspirin, in acute TIA and mild ischaemic stroke reduce the risk of recurrent stroke by up to 80%. In The Lancet, Peter Rothwell and colleagues report fi ndings from an analysis of the individual patient data from all randomised controlled trials of aspirin after ischaemic stroke or TIA, giving fresh insights into the eff ect of aspirin on the timing and severity of recurrent stroke and challenging our understanding of the role of aspirin in secondary stroke prevention. Rothwell and colleagues found that in the three trials of aspirin versus control in acute ischaemic stroke (n=40 531), the overall eff ect of aspirin was indeed modest. However, there was signifi cant heterogeneity according to baseline stroke severity (phet=0·014). Aspirin appeared far more eff ective in reducing the 14 day risk of recurrent ischaemic stroke in patients with mild (OR 0·51, 95% CI 0·34–0·75) and moderate (0·65, 0·44–0·98) neurological damage after stroke, than for those with severe defi cits (OR 1·10, 0·77–1·58). Also, the reduction in recurrent stroke among patients with mild and moderate stroke was as great as half to two-thirds within the fi rst 2–6 days. Moreover, among the 12 trials of secondary prevention of stroke in 15 778 patients with TIA or ischaemic The benefi ts of aspirin in early secondary stroke prevention The HubBLe study can help establish realistic patient expectations and provide a framework for counselling patients. This study has been a trend setter in selecting patient-reported outcomes as the primary endpoint. In context, patient-reported outcomes are now widely used, although this development is recent. Use of a patientcentric qualitative endpoint is underpinned by the highquality health economics model applied in HubBLe. The role of HAL, which has become widely accepted as a safe intervention for grade II–III haemorrhoids, will need re-evaluation. However, HAL might fi nd a niche role as second-line treatment for patients who relapse following a course of RBL and do not wish to have excisional haemorrhoidectomy.